Process Safety Incident Report Form

Directions for Completion: All Process Safety Incidents / Near Misses should be documented and as required
or as appropriate investigated to determine the underlying causes of the event.
a. Complete and submit this form to the EHS Dept. Process Safety Program Manager within 48 hours
of the incident (Eisenhower Parking Deck)
b. Complete as much information as available and then sign and date the form

Incident Number (completed by EHS Dept.):

I. Covered Process / Personnel Information

1. Date of incident: Time of Incident:

2. Location (include Bldg.#):
3. Department:
4. Incident Type: (e.g. Near Miss, PSM, Environmental, etc.)
5. If Incident Resulted in an Injury – List Type:
6. Individual name(s), title(s) and organization if not with Penn State:

7. Witnesses, if any:
8. Incident Reported To: Date/Time Reported:
II. Incident Description and Event Details

9. Incident Description, including details on events leading to the event, materials involved, PPE / tools used,
condition and size of containers/tanks, estimated quantity spilled/released, extent of any injuries (requires separate
documentation), and response:

10. Immediate measures taken to mitigate immediate hazards:

11. Provide additional information on event, location, equipment associated with the event including a sketch, photos
or other details on the event as appropriate:

12. Name of Individual Completing Initial Report and Date Submitted to EHS:
 III. Incident Analysis / Investigation Details

13. Time & Date Incident Investigation began:

14. Investigation Conducted by (Names & Titles):

15. Date Incident Investigation Completed:

16. Outline the contributing factors associated with the Immediate Cause(s) – check all that apply and include
additional detail:
□ Location / Premises – anything about the condition of the workplace that contributed to the adverse event (e.g.
access, egress, lighting, ventilation, housekeeping, area used as designed, etc.):

□ Plant / Equipment or Material - equipment being used contributed to the adverse event (e.g. proper equipment,
adequate controls or guards, properly maintained, etc.):

□ Process / Procedures - instructions or information available contributed to adverse event (e.g. procedures
instructions available & up to date, training conducted, procedures followed, realistic & adequate, etc.):

□ People involved contributed to incident - anything about the people involved contributed to the adverse event
(e.g. suited for job/tasks, competency, adherence to established procedures, etc.):

17. Outline the Root Cause(s) associated with incident – check all that apply and include additional detail:
□ Control (e.g. workplace / activities adequately supervised, adequate resources for tasks, oversight of
contractors, accountability, etc.):

□ Co-operation (e.g. employees involved in assessing / determining workplace arrangements,

establishing safe working procedures, etc.):

□ Communication (e.g. responsibilities clearly defined/ understood, written instructions available & clear,
communications to contractors effective, communications between employees and supervisors effective, etc.):
 □ Competence – Training & Suitability (e.g. people involved suitable for activity, process safety and H&S
training needs identified / effectively delivered, competency verified, etc.):

□ Design and Implementation (e.g. workplace / equipment design considering process safety and H&S
requirements, controls / displays designed to reduce human error, appropriate arrangements to maintain
equipment, addressing defects / repairs, etc.):

□ Risk Assessment – (e.g. were the hazards identified and suitable controls implemented, were they adequate,
did they correctly identify the risks, up-to-date, appropriate technical standards utilized, were adequate risk
control measures identified, etc.):

IV. Corrective and Preventive Actions

18. Recommended Corrective Actions (include responsible individual and due date)
18.1 Immediate Cause(s):

18.2 Root Cause(s):

19. Recommended Preventive Actions (include responsible individual and due date)

20. If appropriate, Assessment of Corrective/Preventive Actions implemented

20.1 Conducted by: Date:
20.2 Assessment Summary (consider if the Corrective/Preventive Actions were closed within the required
timeline and if they were effective in addressing the contributing causes to the incident)

21. Incident Review Meeting (list attendees & date if a Review Meeting was held):

21.1 List any additional Recommendations/Actions identified by Review Team

V. Incident Closure

22. Incident Closure (after Corrective/Preventive Actions are closed, Incident Report should be closed)

Name: Date:

03/2016 [PSM-SOP-UN-008ata]